Thanks, John. Welcome, everybody. I'm glad I get to go first because this is probably the most attentive audience we're going to have because you'll have some fatigue as the two days goes on. If I can just start in preface. Take this opportunity to say that this is probably one of the first times and maybe the only time during your residency training where you're going to have a bunch of people staff members helpers in the lab faculty that are here for your benefit and we're all every one of us I can tell you we've been together doing this for many years now. We want you to succeed, and we want you to gain everything that you need to gain while you're here so I've been a participant and now a faculty now for a while and my advice is to have a plan stay focused and really enjoy pick everybody's brains. And hopefully, when you leave here, you'll, you'll, you'll say this course was awesome. And we continue to have this opportunity to educate and collaborate. What I'm going to share with you today is my talk on meniscus tears. And what I'm going to do is give a brief introduction of anatomy and I think it's important to understand anatomy. It seems like an easy topic but I guarantee you if you do this long enough you're going to be in surgery and you're going to go gosh should I repair that or should I take it out or what the heck should I do with it. And so you're going to have to default to what you know about anatomy healing and clinical outcomes. Meniscus tears are probably the most common injury to the knee. Probably the most common surgical outpatient surgical procedure that's done, at least in the United States you're talking about millions or so patients per year that get surgery for meniscus tears. In general, the outer zone or periphery of the meniscus is well vascularized and the blood supply comes in from the outside periphery and go centrally, which is more a vascular and Steve Aronofsky did, of course, Sentinel work on that. Back in the early 80s and I'll show you a little bit about that. But in general, if you keep this in mind I think that's sort of the gestalt. There is an emphasis, contemporary emphasis placed on how to get more centrally vascular tears to heal because we know that preservation of the meniscus tends to preserve the joint cartilage tissue from degenerating. But of course, as I would argue with my predecessor Ben Graff, is a crappy meniscus better than a relatively good but less robust meniscus? And I'm not sure we have the answer to that just yet. We know that meniscus tears or meniscus injury is an independent predictor of arthritis progression. This was a study based out of the Yellow Journal review showing some of the pearls and pitfalls of whether to do a partial meniscectomy or repair the meniscus. And you can see here that partial meniscectomy tends to have lower revision rates, but meniscus repairs that heal tend to have improved clinical outcomes. But when you look at arthritis, they were unable to detect a difference beyond about six years with regards to how much arthritis patients were having. Certainly if you go and take a clamp and have the meniscus removed like my father-in-law had back before arthroscopy was really a thing, we don't do that anymore. So really you need to evaluate your patients, make a plan, and go from there with regards to patients' symptomatology. This is the picture from Arnosky's work where he stained the capillary plexus and then sectioned it. And you can see here on this coronal cross section that the blood supply is coming in from the pericapsular tissue, and it's infusing into the meniscus from the periphery in through that tissue. So this is the, let me see if I can point this out, this is the meniscus coming along here, upper border of the meniscus. You're missing just that very point here, lower border here, capsule and pericapsular tissue, and then you have this pericapsular plexus here. This is the cartilage femur, cartilage tibia, and you can see that maybe a third or so of the periphery has relatively good blood supply and then it starts to really trickle off. So you have to be really cautious about these tears that are centrally based, even in young patients, because I don't feel that they heal very well. So this is an axial view of the same thing, showing that particularly along the posterior horn and root, those have a very rich, robust vascular supply, so you can probably get away with a little bit more along the horns and roots, with one exception being the lateral meniscus, where this is where the popliteus tendon, one of two interarticular tendons in the body exists and so along that area there, you can see that there's almost like defect there and those are some special considerations as to what to do with the meniscus tears there and that's probably for another talk. It's also important to understand that the menisci itself are quite anatomically distinct and they function differently. The medial meniscus is less mobile, it is more load-bearing and therefore more commonly torn. The lateral meniscus is more mobile, covers more of the surface area of the joint of the tibial plateau and therefore less commonly torn than the medial meniscus, but is more commonly injured, let's say in ACL injury and other ligamentous tears. It's also important to understand when we think about root attachments, so the meniscus acts like a gasket and it's anchored to the tibia via an anterior root and a posterior root and those have been shown to be anatomically consistent, so if you look for them you will find it, if you don't look for them, you're going to miss it, so be sure you can visualize those root attachments well and you'll pick up a lot of injuries there. Meniscus is fibrocartilage like your ear and the tip of your nose. It's made up of collagens but mostly type 1 collagen and it's arranged, the collagen fibers are arranged in a radial and circumferential pattern and this allows the meniscus to function as that gasket and as it transmits load through axial compression, it does really well. It doesn't do really well with compression and torsion and that's where you're going to get the tears. Patient evaluation I think is critical to success. Patients that come in with pain in their knee need to be queried for other types of symptoms like joint line tenderness, particularly locking and catching, squatting and swelling are other clues. And then examination, joint line tenderness tends to be the most sensitive finding and then you're going to do some provocative maneuvers such as compression tests, thalassate tests where you have them stand on one leg, partially squat and rotate, that tends to be the most accurate test and then of course your McMurray's. I've seen maybe a handful of true McMurray's tests where you can get a clunk with a meniscus that's displaced but most of the time we're looking for pain along that particular joint line whether it be medial or lateral. I still think radiographic evaluation is an important imaging tool. It looks for arthritis, alignment and somebody who did limb preservation fellowship training, it'll pick up some unicorns and zebras sometimes within the bone so I think it's really important to have that. It's readily available. This is what I do for the knee. This is a four view knee, you have a bilateral standing AP view here, an ipsilateral lateral view here. This is a partially squatting bilateral PA view and of course your sunrise merchant or patellar views here. And this is pretty comprehensive. Sometimes, you may also want a long leg standing or TVO view to help you with alignment characteristics, particularly in the setting of a varus knee, valgus knee, or if you're going to correct the alignment with osteotomies. MRI for sure has become more commonplace for diagnosing of meniscus tears. This wasn't always the case but now we have readily access to MRI, it's become rather inexpensive to do this for the most part. But it's, there's been a lot of research as to what characteristics on MRI constitutes a true meniscus tear, because many patients will have signal within the meniscus. And so you got to be careful on that. I was fortunate enough to train with Dr. DeSmet and Ben Graff, who did a lot of the work with regards to MRI characteristics and sports injury. There's different configurations of meniscus signal I won't bore you with the details but suffice it to say, we really want to see signal within the meniscus that actually extends to the periphery of the triangle. And if you see that then you're pretty confident that is a true sort of true tear. These types of signals that are in the body of the meniscus particularly in younger patients let's say teenagers, that can be absolutely normal. So you got to be really cautious about that. Here's an example of what we showed in the cartoon. This is a sagittal T1 sequence, you can see the posterior horn. Here, you can see signal within the meniscus extending to the superior surface of that triangle and that that would indicate a tear that that meniscus. Here's a even better example of what I'm describing, where you have tear characteristics and signal coming in through the superior border of the meniscus as well as the inferior aspect of that meniscus. And then these tears are sort of that parrot beak extension tears and these can be really symptomatic for patients they can cause the mechanical characteristics and probably need to be treated. Contrast this with an example of signal within the posterior horn of the meniscus that doesn't extend to the surface we can very see very well see the discrete characteristics of the triangle here the meniscus and signal stays within the body of the meniscus. This is unlikely to be a tear of the meniscus. And these patients you might want to steer more towards therapy see what happens because a lot of patients, even though they probably feel like it's going to be the end of the world if you give them a little time to get better, oftentimes they will in these types of situations. I won't talk too much about that again I will emphasize that adolescent patients, this can be part of the vascular tissue network so don't get try not to get fooled with that. So in general when you're looking at MRI evaluations, you really want to see the tear extend to that surface on two or more images. And you can be pretty confident upwards of 95% that that's symptomatic type of tear that you can be really intervene and make it better for patients. It's possible you can still have tears if you only see this on one sequence. One image sequence of the MRI. But if you really don't see it extend to the surface then that's unlikely to be a meniscus tear. Meniscus doesn't really apply to bucket handle tears, central radial tears, particularly of the lateral meniscus there's a problem with the lateral meniscus on imaging it's very sometimes very difficult and you will even advanced musculoskeletal radiologists argue about what constitutes injury to the lateral meniscus. And then root tears can sometimes be difficult, particularly of the lateral posterior meniscus root. A typical example of a bucket handle tear the medial meniscus, so the tear is a long peripheral tear where the meniscus fragment has flipped over just like a handle of a bucket and get stuck in the notch adjacent to the PCL. So you'll oftentimes see this secondary sort of double PCL sign which is this this is the, this whole thing is the posterior and body of the meniscus flipped into the notch the anterior portion is right here. And this is the coronal sequence, showing the same thing. You can see the ACL here PCL here, and then that meniscus fragment bucketed over there. Radial tears would look something like I have in the next slide. And this is what you would see so this is the bow tie sign here on the MRI sagittal sequence you can see that the bow ties cut in half, and that's a central radial tear this is what you'll see at the time of surgery, I have another example of this, and those can be somewhat symptomatic particularly for the lateral meniscus on these ones I try to treat fairly aggressively, because they do fairly well coming in there and you don't have to remove a whole lot of tissue. If you leave these and it continues to tear and rip apart, and you end up with a parrot beak tear and some larger meniscus problem down the road. I won't discuss too much of discoid meniscus tears but discoid meniscus is generally a lateral meniscus that's quite robust and prone to tearing. And I think that's all I'm really going to say about that here. It's important to know root tears as well. These can be a fooler but we're getting better at them. Over the years this is a sagittal sequence here on the left, you can see that you, we have the triangle of the meniscus anterior here, and we have none of the that posterior meniscus triangle here what we Sometimes you'll even see the outline of where the meniscus tissue should be and it won't have the inner substance dark sequence characteristic. This is a coronal T2 example of that where you have a very clear avulsion of the meniscus as it attaches into its root. And these ones we try to treat fairly aggressively because they can be fixed oftentimes in the right clinical situation. Tear classification is an important consideration as well. There's many ways to classify things in orthopedics. One of the most simple ways to do this if you don't know anything else, you can classify this more acute or degenerative. Certainly an acute tear is more likely to heal more likely to be a peripheral and vertical and orientation. And so I contrast that with more degenerative types of meniscus tears. Like you see here, this is an example of a complex degenerative posterior horn tear of the meniscus that's unlikely to heal and more commonly treated with partial meniscectomies. You can also classify the tear based on the tear patterns. So you can have the radial tear, which looks like this. I showed an example of that in the previous slide. If that radial tear extends a bit into the substance of the meniscus, you can get a parrot beak type tear configuration where this piece becomes really problematic for patients. You can get a vertical oriented tear. If that tear becomes propagated, you can lead to a bucket handle type tear, which looks something like that. And these types of tear configurations can be helpful when you think about how to repair or remove these tissues with surgery. Tears can also be classified by their vascularity and location. So we oftentimes will classify peripheral tears that have some vascular supply as red, red tears. And then so those tears would be sort of in this one, number one zone here. And those ones you can be pretty confident and aggressive to fix. Tears of this very central third of the meniscus here are classified as white, white. And then, of course, as you could probably guess, in between into this two areas, we would classify that as red, white zone. So it's kind of a 50-50 shot at whether or not that'll heal. So you have to take other considerations into, well, other things into consideration. So I think I will say meniscus preservation is important, but also, you know, you got to take into consideration healing. The more I'm into practice, the more I start thinking, gosh, you know, maybe we don't have to be cowboys and repair every single meniscus tear. All it takes is for you to go in to about maybe two or three times where you try to do this, and now you have suture anchors everywhere. We just had a triathlete. They tried to do some magical repair, and now he's got anchors floating around in his knee. And you're taking out more meniscus later than if you would have just bit the bullet the first time and just trimmed it out. And so it's really important to consider how likely is this meniscus going to heal. And this is based on an article about 10 years ago given pretty discrete indications for meniscus repair. So you want that peripheral red, red zone. Vertical tears do very well. Patient age is a consideration, and you want no malalignment. If they're really varus, that tissue's probably not going to do really well. When you do a repair and how you manage the repair really requires anatomy of the tear location as well as your knee anatomy, so super important. Clinically, this is what it kind of looks like for a planned inside-out repair. This is the joint line here. This is our planned incision, and I'm going to show this in the lab and talk to your table trainers. You will, everybody will go through this. This is the medial knee. You're going to bias your incision just slightly inferior to accommodate for the slope of the tibia and the passage of the sutures, and you're going to get down to the superficial tissue. Really, on the medial side, you really got to watch for the branches of the saphenous nerve that are coming through here, so you want to try and protect those if you can. On the medial side, there is a fascial band that you got to slip. You got to cut it and open it there, and then you're going to stick a spoon, speculum, some sort of retractor back here with the knee flexed. This is the capsule of the knee here. You can oftentimes see it. It'll kind of pooch out due to the fluid that's in the knee from the scope, and this gastrocnemius muscle is behind the speculum here. There's other types of suture passing devices. There's zone-specific cannulas. They have a device that you can sort of manage this on your own via this gun, and then this is what it looks like. You can tie sequentially. You can sort of tie as you go, or you can also pass and tag and then tie later, but the important thing is to get a very, very good repair. The inside-out technique is the gold standard, but does require some expertise in handling that. This is what it would look like. This is one of our wrestlers and did very, very well with this. This is what it looks like on the lateral side, kind of cartoon illustration. I know this is a lot to look at, but I want to just kind of throw this out at you so you have a visualization in your mind's eye of what is going to happen. Here you can see there's the retractor protecting the gastroc. This is the front of the knee. This is the back of the knee. You have this peripheral vertical tear here. Oftentimes, you will view through the same side portal and then come at the tear in the contralateral portal, but this is sort of up for whatever the tear configuration is. You can certainly switch this, and then this is what it looks like anatomically on the lateral side. You're going to stay just anterior and superior to the biceps femoris tendon and then just posterior to the LCL, and if you do that, you're going to be totally fine. What about anterior tears? Well, access issue is a problem. This is sort of an anterior body horn junction tear in one of our skaters. The ice skaters get this. It's kind of hard because it's right underneath your camera, so you got to use kind of this accessory Walzak portal, which can kind of help you, and I can show you how to do that, but they do have back biters and other equipment that kind of do the same thing, but visualization is an issue, so portal placement, as Dr. Ciccone said yesterday, is really super crucial with this. So this is what it looks like in that same patient, and you can see here that you can't really see underneath this tissue, and so if you kind of use a high accessory portal right next to the patella, now you can view this whole area here, and you just don't want to leave tears down here, and you won't be able to see that unless you do this technique. 70-degree scope can be your friend as well. I know that might be something that people aren't used to, but you should get used to it. Posterior root tears look like this. You can see that you can have the avulsed fragment of the meniscus back here. This is the remnant that's attached to the tibia, and these are repairable oftentimes, and I'm very aggressive repairing this because these are really a harbinger for arthritis progression. So you got to understand that posterior root tears are really bad actors, and you got to be aggressive to do this, and more and more, if you don't look for them, you won't find them, so you got to be on top of it, but they're common, and they get more common because we're looking for them. They account for nearly one-fifth to one-fourth of all meniscus tears, and really, really high likelihood of arthritis, so this is a research interest of mine because it goes along with cartilage preservation, and can be an under-recognized cause of insufficiency fractures, and I probably should put a slide in there what that looks like, and so if you repair this, patients do well. This is just more information on this. You can read a little bit about that, but really, meniscus tears are really super common, and as you get older, probably everybody in this room is going to have some problem with it, so really be diligent about that and really understand that those horn root tears are really under-recognized, so please look for them. They can also be classified. LaPrade did the classification system for this, and this is quite helpful to see which one of these tears are really amendable to repair and which ones are not. Medial is the most common. This is associated with arthritis or some joint space narrowing. Lateral is about 10% of ACL tears have a lateral meniscus root tear, so again, ACL injury, please look for them. They present differently from other meniscus tears. Patients have posterior pain. They often feel like when they squat, came up from a squat, they felt a pop in the back of their knee, and they hurt in the back, so that's where you got to kind of be like, all right, these ones are there. These ones tend not to do great with, you know, two months of rehab. They just get worse and probably need to be treated sooner rather than later, and this is an algorithm kind of showing that from a recent study, I believe, in 2016. So, I'm going to go through some of the particulars of the technique now, so if you were sleeping, now's a good time to pay attention as to what you're going to do in the lab. Again, critical role, the knee function, repair when possible as long as it's a high likelihood to heal, and these are those vertical tears, 10 millimeters, so one centimeter or more. The red red zone are the ones that heal most commonly. You can take a swing at some of the more central tears in certain clinical instances. Bucket handle tears do very well because these are often peripheral vertical tears. Root tears, again, because of their vascular supply, and active patients without arthritis or if you're going to do ligament reconstruction. Again, radial tears, talk to your table trainers and young patients. Some people are pushing the limits on this. I haven't gone that route, but I'm certainly not judgmental to it because it does make some sense to me, but this is the problem I have. Healing rates depend on location. Again, peripheral tears do pretty well. Once you get beyond that one-third of the periphery, you start to have issues. So, there's a big push to see if you can enhance repairs, and again, I've done trepanation. I've rasped the edge or take out portions of that peripheral meniscus to try to stabilize the meniscus to some pericapsular tissue. Ligament reconstruction is probably a good time to try to push the limits a little bit because you've got a hemorrhage inside the knee and you have healing factors that are there. Some people are doing fibrin clots and glue and things like that to help enhance repair, and PRP is something that you could consider as well. If it's an isolated meniscus tear in an athlete, I'll oftentimes knock a hole into the notch area to stimulate some bone marrow elements to circulate into the joint, and that seems to be somewhat supported by pretty good evidence. Again, inside-out repair is the gold standard. This is what you want to learn while you're in the lab. This works really well for posterior tears of the horn and midbody. Assess the tear location for repairability, and again, try to enhance the repair. There's a zone-specific cannula set. You're going to get that in the lab today. You really need assistance. So this is the issue you're going to run into. You really need to kind of know what's happening because you're going to slowly advance the needle, and it's going to come out the knee, and there's nerves and vessels and really important stuff that you're going to want to protect. And so somebody's got to catch the needle and somebody's got to throw the needle, and somebody's got to hold the scope. So it's helpful to have some staff that's familiar with what you're doing. If you're not, if you don't have that, then it's a little bit of a goat rodeo. So yeah. The medial approach looks something like this. So this is a good cartoon illustration of what we're referring to. You're going to be just in front of the pes anserine tendons, again, biasing your incision slightly inferior to accommodate for the posterior slope of the tibia. There'll be a fascial band below that that you'll need to incise and then bluntly dissect the capsule from the medial gastroc. And once you do that, you're going to have that knee flexed. Once you do that, then you're totally golden. So about three centimeter incision, just posterior to the MCL but in front of the pes. Again, we talked about that. A sartorial fascia does lay there, so you need to incise that fascia, and it's definitely there. If you put your finger in there, you're going to end up with like a mallet finger because it won't open. And you're going to place the retractor anterior to the gastroc. Lateral incision is a little bit different. Of course, you have the common peroneal nerve is going to be down there. So you got to stay anterior to the biceps femoris through your first layer, and then stay just posterior to the LCL, and then the rest is sort of the same. So you want to make sure you don't extend that incision below that fibular head just to not get yourself in a position where the peroneal nerve is going to be an issue. Again, splitting the IT band through that biceps, that's your first interval superficially, and then deep, you're going to elevate that lateral gastroc off the posterior capsule. There's less fibrous bands laterally than there is medially, so oftentimes you can put your finger back there and sort of bluntly dissect that on that deep layer. And again, you're going to place your retractor back there for protection. Utilize cannulas to pass sutures around the tear. I have a video of this I want to get to, so I'm going to kind of move through this tissue, move through these slides a little bit quicker. Again, you're going to go through that contralateral portal most commonly, so you're going to view ipsilaterally, go contralaterally through it. That usually works pretty darn good. You're going to have somebody pass the sutures through the long needles about five millimeters at a time with a needle driver, and usually I do one, two, three, and I'll count, and if I go more than three and we can't find the needle back there, then I stop, take it out, and reassess that. You don't want to put your finger back there when the needle's going through there because I guarantee you, you will cut your glove because the tip of the needle is super sharp, so you want to kind of dig back there with a needle driver rather than your finger. You're going to take the sutures or tie them, and we talked a little bit about this kind of stuff here, so I won't bore you with the details. Outside-in repair is primarily for anterior tears. It's less commonly used. If you do a meniscus transplant, you need to do an outside-in technique, and we can go over that, but this is fairly simple to do. Two 18-gauge needles and some PDS suture is all you really need, but they do have a kit that allows it to be done a little bit easier, and then you'll suture it to the anterior peripheral capsule. Sometimes the skin is kind of the most annoying part of this technique. You got to make sure you don't have a skin bridge or tie over the skin. You want to be underneath that, and again, 70-degree scope can be your best friend. So, we talked about what you need for an outside-in technique. This is the set, but you can use two 18-gauge spinal needles and a PDS suture. Again, you're going to place the needle across the tear, and we'll do this in the lab. Shuttle a PDS, and then you can take that PDS suture shuttling device and shuttle a more permanent suture in there if you so desire. Tissue bridge is the issue with this, so the issue is tissue, so keep that in mind as you go, and you're going to tie the suture over the capsule. This is sort of what it looks like when it's done for a more anterior horn body junction tear. All-inside repair is probably the most common technique that you're going to see nowadays. The meniscus devices, every company has them. They kind of work the same way. It's very easy to use. They're very quick. The results of all-inside repair tend to be on par with the inside-out repair at this point with the technology that we have. The good thing is it can be done with the limited assistance, so you can kind of do it all yourself pretty much no matter where that tear is. I'm going to go here just to show this. It's expensive, and it costs the hospital a lot of money, so every time you open one of these things up, it's hundreds of dollars as opposed to maybe, you know, 50 bucks at most for the other ones, and so if you burn through like 10 of these, it's really expensive, and you're going to go in the hole, so keep that in mind. These do misfire, so again, be cognizant of what you're doing. Hospitals that you're going to work with want value, and so be sure to do that. You'll learn this in the lab. I'm just going to go through this here. You have to also be careful of chondral damage, so as you're putting that suture device in there, the tip is really sharp, and if you don't see it come into the joint, you'll put a racing stripe right across some good cartilage, so don't do that. All right, so I'm going to finish up here just showing you some examples so you guys can get in the lab and do your thing, so this is an example of a flap-type tear, the posterior horn. Here's that tissue here. It's through the white, white zone. You're going to probably treat this with minisectomy. This is an example of, hopefully this will run. This is a great example of, thanks to Doug for providing this because it's such a great example of video of a peripheral, vertical peripheral tear. Probe is in there. It's the posterior horn of medial meniscus. You can see it's a displaceable meniscus tear. The meniscus, the probe is about five millimeters, so you could imagine that double that is about your one centimeter, and you can see here in this example that that tear extends quite more than one centimeter, so this one is juicy for a repair. Here's another example of a vertical longitudinal tear that went into a bucket handle, so here's the meniscus stuck in the notch here. Hopefully this will run, and you can see here there's hemorrhage within the meniscus here where it's been bruised up. It's twisted on itself, and so again, this is one where you would be likely to try and get this to be repaired because there's good likelihood of healing, and plus you don't want to take that whole tissue out if you can help it, so this is what your meniscus repair is going to look like from inside the joint. Again, viewing through the ipsilateral portal, working through the contralateral portal, using a zone-specific cannula that's the metal piece that you see here. That's the long needle tip. You're going to put the needle out so you can see it, stab the meniscus, and then your assistant is going to gradually, five millimeters at a time, push that suture through that meniscus tissue. Somebody's going to receive the meniscus tissue. They're going to look for it in the back of the knee, hopefully right where you put your retractor and not through the skin and all that stuff, so that's why it's really important to watch. It can be really hard because sometimes the light is not shining because you're kind of looking up this way at it, and then once that's in, you're going to take the second needle, poke it through here, so we got one suture passed, another suture coming in, going to go more peripherally on this one, stab it, and then advance that needle through so you have both leaflets. This is a vertical orientation, which is what you're going to try and shoot for because it's the strongest, more robust configuration, and then once that needle's passed, the person who caught the suture needle is going to pull that suture through, and the loop should come right into the joint here. You're going to see that, and then you have that beautiful tear, so repair. That's what it's going to look like. Here's an example now of an outside-in meniscus repair, so we have one PDS suture already passed. You're going to stick the needle through the front of the knee and shuttle your PDS suture through the capsule and in through your more permanent suture here, and then you're going to see this tug on there, so you can see the meniscus come right up to the capsule there, and then you're going to tie that over the top of the capsule, and so this is the anterior tear repair configuration here. There you go, right like that, so that's tying it right to the anterior capsule. This is a meniscal root avulsion. I'm going to finish with this, so we're going to be getting out of here, so just bear with me one more second here. This is the meniscus here torn from the tibia. We can repair this through bone tunnels through the tibia. This tear doesn't extend into the body too much, so we'll be able to get some good purchase of sutures here in. We can use a myriad of suture shuttling devices to pass sutures through that posterior root and horn junction, so you pass your sutures, you'll shuttle those sutures through a passer in through the tibial tunnel, which is this black thing right there. That loop is going to then pull all those sutures down, and you can tie those sutures down to the tibia, and you can repair that right down to the tibia for your meniscus root avulsions, and we'll go through all that stuff in the lab too. So thanks for bearing with me. I'm a little bit over time, but I did pretty good, threw a lot at you, and so we're all here. I don't know if you want to just break in there and just go, or you want to say a few more. So anyway, thank you for your attention on that.

meniscus tears

anatomy

healing potential

clinical outcomes

repair methods

tear configurations

patient evaluation